Gliederung

When faced with patient nonadherence clinicians face a quandary. Nonadherence reduces the value of healthcare, hurts patients sometimes, and always degrades the patient-clinician relationship. Nonadherence particularly among patients with multiple chronic conditions offers a vantage point for the analysis of evidence translation that places the patient at the center and offers some challenges to the guideline community.

Patients with chronic conditions that opt out of some aspect of their healthcare may do so because they lack knowledge about the disease or treatment or have not truly agreed to take the treatment. Patient education, improvements in professional communication, and shared decision making may help. The latter involves patients and clinicians sharing knowledge about the available options, deliberating about the relative merits of these options, and making a consensus decision. Guidelines might recommend shared decision making for weak recommendations in which there is uncertainty as to how act or when the best option depends on patient circumstances or values. But also, guidelines may promote shared decision making for strong recommendations for which patient adherence is essential to ensure net benefit.

Patients with chronic conditions may opt out of some aspect of healthcare not because of ignorance or informed objection, but because the recommendation cannot be implemented given the patient’s existing demands for their time, effort, and attention. Clinicians need to prioritize with the patient which treatments are most likely to advance patient goals while having the lightest burden of treatment. Guidelines and quality-of-care metrics often interfere with this prioritization work. Guidelines must modulating the strength of their recommendations based on patient goals and circumstances, being mindful of the burden these recommendations place on the already complex lives of these patients. For these patients nonadherence may be an indicator not of poor patienthood, but of lousy clinical policy.